Thursday, October 31, 2013

If a tobacco company were to publicly state that we don't know if smoking is any more hazardous than using non-tobacco, non-combusted electronic cigarettes, we would instantly attack those companies and perhaps initiate a lawsuit, claiming public fraud. We would cite the damages caused to the public by undermining their appreciation of the serious hazards of cigarette smoking by even suggesting that these products, which kill more than 400,000 Americans each year, may be no more hazardous than inhaling aerosol from a mixture of propylene glycol and nicotine (that contains no tobacco and involves no combustion).

But what happens when physicians or public health practitioners make the exact same statement to the public?

The Rest of the Story

On the same day, not one but two public health practitioners made exactly this assertion.

According to an article in the Star-Press, the Tobacco-Free Coalition of Delaware County (Ohio) stated that there is no research to tell whether cigarettes are any more hazardous than electronic cigarette use.

According to the article: "If you thought e-cigarettes, the tobacco-less vaporizing devices, are
safer than smoking traditional products, the Tobacco-Free Coalition of
Delaware County wants you to think again.“The truth is, we don’t have the research to tell us these e-cigarettes are helping people stop smoking or that they aren’t as dangerous as regular cigarettes. We
just don’t know,” said Cecilia Williams, the coalition’s secretary. She
is also the account representative for the region’s American Cancer
Society office."

It doesn't end there. According to the article: "Despite the lack of evidence-based information on the smoke-fee and
tobacco-free alternatives, Bastin [from the Tobacco-Free Coalition of Hancock County] and others reported these products
have the potential to cause oral and esophageal cancers as well as
increase heart disease based on the ingredients used."

Obviously, it is absurd to claim that cigarettes are no more hazardous than electronic cigarettes. Even the tobacco companies do not dispute that products like electronic cigarettes, which do not contain tobacco nor involve a combustion process, are safer than traditional tobacco cigarettes.

Moreover, there is absolutely no evidence that electronic cigarettes cause oral cancer, esophageal cancer, or heart disease. The Tobacco-Free Coalition of Hancock County is just making this up. The Coalition is fabricating scientific statements that are not supported by any evidence. What we do know is that electronic cigarettes greatly reduce the risks of oral cancer, esophageal cancer, and heart disease for smokers who quit smoking using these products.

On the same day, a physician from Wake Forest University made the same statement, asserting that we don't yet know whether smoking cigarettes is any more hazardous than using electronic cigarettes.

According to an article in the Old Gold & Black newspaper: "E-cigarettes do not contain many of the 4,000 chemicals found in
cigarette smoke, including the cancer-causing agents and carbon
monoxide. Because they vaporize the nicotine, they also reduce the risk
of second-hand smoke for bystanders. “They seem better for you than a regular cigarette,” said junior
Colin Simon who echoes the belief of many smokers who have jumped on the
e-cigarette bandwagon. ... “People perceive them as safer, but we do not yet know if that is
true,” said tobacco expert John Spangler of Wake Forest Baptist Medical
Center. “We do not fully understand the health effects of electronic
cigarettes.”"

While it is true that we do not fully understand the health effects of electronic cigarettes, it is not true that we don't yet know if electronic cigarettes are safer than tobacco cigarettes. Again, even the cigarette companies themselves would not deny that electronic cigarettes are safer. In fact, this is why all the major tobacco companies are now getting into the electronic cigarette business.

The rest of the story is that the false and misleading information about electronic cigarettes being disseminated by tobacco control advocates and practitioners can no longer be viewed simply as isolated misstatements or slips of the tongue. This is now a campaign to discourage electronic cigarette use that is based on the dissemination of false and misleading information.

In the first study to examine the hypothesis that electronic cigarettes are a gateway for youth to become addicted to cigarettes, Dr. Ted Wagener from the University of Oklahoma Health Sciences Center reports being able to find only one young person who initiated nicotine use with e-cigarettes and then went on to smoke cigarettes, out of a sample of 1,300 college students.

The study has not yet been published, but it was presented Tuesday at the annual meeting of the American Association for Cancer Research in Washington, D.C.

According to Brenda Goodman's HealthDayarticle summarizing the study: "E-cigarettes don't appear to entice teens to try smoking tobacco, a new study says. ... Last month, the U.S. Centers for Disease Control and Prevention
warned that "vaping," or inhaling the nicotine vapors from e-cigarettes,
might be a dangerous new fad that could set teens up for smoking. In just one year, the number of kids in grades six through 12 who
said they'd ever tried an e-cigarette more than doubled, rising from 3.3
percent to 6.8 percent. Among the 2.1 percent who said they were
current e-cigarette users, more than three-quarters said they also
smoked regular cigarettes. Given that overlap, many health experts worried that e-cigarettes
might be acting like a gateway drug, sucking kids more deeply into
nicotine addiction, and law officials urged the U.S. Food and Drug
Administration to regulate e-cigarettes as tobacco products."

"The new study suggests that may not be the case. Researchers surveyed 1,300 college students about their tobacco and nicotine use. The average age of study participants was 19. "We asked what the first tobacco product they ever tried was and what
their current tobacco use looked like," said researcher Theodore
Wagener, an assistant professor of general and community pediatrics at
the University of Oklahoma Health Sciences Center, in Oklahoma City. Overall, 43 students said their first nicotine product was an
e-cigarette. Of that group, only one person said they went on to smoke
regular cigarettes. And the vast majority who started with e-cigarettes
said they weren't currently using any nicotine or tobacco."

"It didn't seem as though it really proved to be a gateway to
anything," said Wagener, who presented his findings at a meeting of the
American Association for Cancer Research, in National Harbor, Md."

The Rest of the Story

This study provides preliminary evidence that electronic cigarettes are not currently serving as a major gateway to cigarette smoking. Of course, more studies of this nature, as well as longitudinal studies, are necessary to firmly answer this question. And importantly, this only reflects the current situation and things can change at any time. It is important that we remain vigilant and closely monitor youth electronic cigarette use over time.

I should also make it clear that in no way am I arguing that sales and marketing restrictions are not needed. In fact, I am hoping that the FDA will promulgate regulations that do strictly regulate the sale and marketing of electronic cigarettes to youth.

What this evidence does highlight is how unfortunate it was that CDC Director Dr. Thomas Frieden disseminated to the public a conclusion about this research question, telling the public that we already know the answer and that electronic cigarettes are a gateway to tobacco addiction. Dr. Frieden stated that: "many kids are starting out with e-cigarettes and then going
on to smoke conventional cigarettes."

Unfortunately, this premature speculation (or conclusion, as the above statement does not seem to be speculative) led to widespread media dissemination to the public of the news that electronic cigarettes are a gateway to tobacco addiction. These articles are already having an effect on policy makers throughout the country.
In a Forbes magazine online column today, Jacob Sullum explains how many tobacco control advocates, including Dr. Frieden, "jumped all over CDC survey data indicating
that the percentage of teenagers who have tried e-cigarettes doubled
(from 3.3 percent to 6.8 percent) between 2011 and 2012." Sullum writes: "'Many teens who start with e-cigarettes may be condemned to struggling
with a lifelong addiction to nicotine and conventional cigarettes,' CDC
Director Tom Frieden worried.
But the survey data [the CDC data] provided no evidence that e-cigarettes are a
gateway to the conventional kind, and a new study [the Wagener study] casts further doubt on
that hypothesis."

The issue of whether electronic cigarettes serve as a gateway to youth tobacco addiction is a very serious one. It should not be taken lightly. If these products lead to increased cigarette smoking among youth then this harm would offset the benefits of enhanced smoking cessation and electronic cigarettes would no longer have net public health benefits. So this is a crucial research question.

But I emphasize that it is a "question." It does a disservice to the public to draw pre-determined conclusions, as Dr. Frieden did in telling the public that we already have the answer: kids are starting out with e-cigarettes and going on to smoke conventional cigarettes.

Our public policies must be science-based. But when one draws pre-determined conclusions, rather than rely on the scientific evidence, this does not lead to evidence-based policies. My fear is that because of a strong pre-existing ideology against electronic cigarettes because they simulate the physical actions of smoking, tobacco control groups are drawing conclusions based on ideology rather than on science.

Wednesday, October 30, 2013

Pennsylvania's physicians apparently want to make sure that tobacco cigarettes maintain a competitive advantage over the much safer electronic cigarettes, based on their public policy position announced earlier this week following a conference of the Pennsylvania Medical Society. Specifically, the Society called for imposing taxes on electronic cigarettes to increase the price of these products.

Increasing the price of electronic cigarettes would of course serve as a deterrent to their use and would give tobacco cigarettes a great competitive advantage, since the lower cost of electronic cigarettes is currently a major factor that promotes switching from smoking to vaping.

In announcing its support for electronic cigarette taxes, the Pennsylvania Medical Society made it clear that it believes e-cigarettes should be treated no differently than tobacco cigarettes.

According to a Science Dailyrelease: "The potential dangers of electronic cigarettes have members of the
Pennsylvania Medical Society concerned, and until more is known about
the products, the state's physicians believe they should be treated no
differently than tobacco products. Meeting at the Pennsylvania Medical Society's annual House of Delegates
in Hershey on October 26-27, more than 200 physicians voted to address
the issue by calling upon the state legislature to pass electronic
cigarette laws that have safeguards equivalent to existing tobacco laws,
including taxation... ."

The Rest of the Story

It baffles me why the physicians in Pennsylvania would want to encourage continued cigarette smoking by protecting cigarettes from potentially serious competition. This is a move I would have expected to come from cigarette companies (at least before they entered the e-cigarette market), rather than from medical professionals who are charged with protecting the health of their patients.

There is no question that imposing taxes on e-cigarettes will promote continued smoking. Even if the price elasticity of demand for electronic cigarettes is small, taxing these products will decrease their consumption and increase cigarette consumption, as fewer smokers will be drawn to try vaping instead of smoking.

While I certainly agree with treating e-cigarettes similarly to cigarettes with respect to minors' access, it makes no sense to treat these products the same way in other respects. By all means, we should be doing what we can to do the opposite of what the Pennsylvania Medical Society is calling for. We should be trying to give e-cigarettes a competitive advantage over tobacco cigarettes, which are the most hazardous of all tobacco products.

Tuesday, October 29, 2013

In 2007, researchers from Novartis Pharmaceuticals reported the results of a pre-clinical study designed to evaluate the safety of inhaled cyclosporine dissolved in propylene glycol by examining its acute effects in animals.

According to the study abstract: "The objective of these studies
was to evaluate the potential toxicity of aerosolized cyclosporine
formulated in propylene glycol when given by inhalation route to rats
and dogs for 28 days. ... Endpoints used to evaluate
potential toxicity of inhaled cyclosporine were clinical observations,
body weight, food consumption, respiratory functions, toxicokinetics,
and clinical/anatomic pathology. ... There was no unexpected
systemic toxicity or clinically limiting local respiratory toxicity
associated with inhalation exposure to cyclosporine inhalation solution
at exposures up to 2.7 times the maximum human exposure in either rats
or dogs. There were no respiratory or systemic effects of high doses of
propylene glycol relative to air controls. These preclinical studies
demonstrate the safety of aerosolized cyclosporine in propylene glycol
and support its continued clinical investigation in patients undergoing
allogeneic lung transplantation."

The Rest of the Story

This study provides pre-clinical evidence that the use of propylene glycol as an excipient for the delivery of drugs by inhalation appears to be acutely safe.

The study adds to existing evidence of the acute safety of inhaled propylene glycol. However, further study of the potential long-term effects of propylene glycol inhalation is necessary.

Nevertheless, these results help support the contention that the use of electronic cigarettes to quit smoking is a reasonable clinical approach to smoking cessation.

Monday, October 28, 2013

A prominent anti-smoking researcher at the Mayo Clinic has questioned the sanity of electronic cigarette users, stating that "one of the solutions that the nicotine and the e-cigarette is dissolved into is called propylene glycol which is a cousin of antifreeze and why anybody would want to puff on something and put that in their mouth is amazing."

The comments were made during an interview with Dr. Richard Hurt, founder and director of the Mayo Clinic's Nicotine Dependence Center, and are posted on the Mayo Clinic's web site.

In the same interview, Dr. Hurt stated that "we don't have any evidence at all that they [electronic cigarettes] help people to stop smoking."

The Rest of the Story

I find it unfortunate that the Mayo Clinic is questioning the sanity of millions of smokers who are so deeply concerned about their health that they are trying to use a novel method to quit smoking -- one which is much safer than smoking and which has been shown to be at least as effective as nicotine replacement therapy.

Shouldn't ex-smokers who have successfully quit using electronic cigarettes be congratulated and applauded (and encouraged to remain smoke-free) rather than chastised as being insane for using a "cousin to antifreeze."

The Mayo Clinic statement's referral to propylene glycol as a "cousin to antifreeze" is extremely misleading. Unlike the main ingredients in anti-freeze
- ethylene glycol and diethylene glycol - the chemical found in
electronic cigarettes, propylene glycol, is generally regarded as safe.
As we all know, anti-freeze is toxic and the reason for this is that
both ethylene glycol and diethylene glycol are highly toxic.

In contrast to ethylene glycol and diethylene glycol, propylene glycol
is not toxic. In fact, it is a common ingredient of household medical
products such as cough medicines and it was once used commonly in asthma
inhalers.

Should we have advised patients prescribed those inhalers that they were using a drug that was a "cousin to antifreeze"?

Should we advise patients who use cough medicine that they are ingesting a "cousin to antifreeze"?

The truth is that the main ingredients in most anti-freeze are ethylene
glycol and diethylene glycol. This is why anti-freeze is toxic. For
example, the ingredients in Prestone anti-freeze are:
1. Ethylene glycol; and
2. Diethylene glycol

Ethylene glycol is the main ingredient used in most major brands of anti-freeze. Propylene glycol is used in some anti-freeze, but those products are non-toxic. In fact, that is the reason why propylene glycol is used.

The unfortunate part of this story is not simply that the Mayo Clinic is disseminating misleading information. The most unfortunate aspect
of the story is that because of this misinformation, many ex-smokers
who have quit successfully using e-cigarettes may well switch back to
cigarettes out of fear that they are inhaling toxic anti-freeze.

Not only does the Mayo Clinic statement mislead the public about the toxicity of electronic cigarettes and malign the integrity of ex-smokers have successfully quit smoking using these products, but it also disseminates false information about whether or not there is evidence that electronic cigarettes can help some smokers quit.

The statement claims that there is not "any evidence at all" that electronic cigarettes help people stop smoking. However, there are literally thousands of smokers who have quit smoking
successfully using electronic cigarettes. We know this from a
combination of evidence; including testimonials from individual users,
survey evidence, sales data, focus group data, and most recently,
clinical trial results. We don’t yet know exactly the proportion of
smokers who are able to quit successfully using electronic cigarettes,
but at a minimum, the use of these products appears to be at least as
effective as traditional nicotine replacement therapy.

So to claim to the public that there is not "any evidence at all" is, in my view, fraudulent.

The rest of the story is that the Mayo Clinic is not only misleading smokers, but in my opinion it is also fraudulently disseminating information that is intended to deter smokers from quitting using electronic cigarettes. This is tragic, because although the Mayo Clinic encourages smokers to use NRT and drugs instead, the reality is that most of the smokers who have used or are contemplating using electronic cigarettes are smokers who have tried and failed with these "approved" therapies. Telling them they have to stick to the same methods that have failed in the past is tantamount to telling them to remain smokers.

Thursday, October 24, 2013

By the way, I think the very first commenter (Uma) makes a great point: regulation has the potential to greatly impede the market because it is the variety of the products available (different types, brands, flavors, etc.) that allows each smoker to find the product that is best suited to his or her needs.

Also, please note that Jacob Sullum has an excellent piece on electronic cigarettes today in the New York Post.

The Campaign for Tobacco-Free Kids and several other anti-smoking groups have put forward the argument that instead of funding early childhood education as a budget priority, the federal government should tie education for low-income children to continued high levels of cigarette tax revenue.

These organization recently called for the expansion of early childhood education. But instead of suggesting that early childhood education is a budget priority that should be funded with existing revenue or by increasing taxes on the wealthy and on corporations, they argued that for poor children, such education should be tied to continuing high levels of cigarette sales, which would garner the tax revenues that they recommend using to pay for such education.

Among the organizations making the recommendation that early childhood education for low-income children should be tied to cigarette sales were the American Heart Association, American Lung Association, and the American Academy of Pediatrics.

The Rest of the Story

In a sense, this is a perverse policy because it ties the future
funding of early childhood education for low-income children to
continued high levels of cigarette smoking. As such, it also reduces the
incentive for the federal government to take any action which would
substantially decrease cigarette sales. Any such intervention would
threaten the solvency of the early childhood education program. In fact,
the creation of this program of cigarette sales-dependent early
childhood education nearly ensures that the government will not take any
action to severely curtail smoking rates.

What the
cigarette revenue should be used for is comprehensive tobacco control
programs in all 50 states. These programs should include anti-smoking
media campaigns, like the "truth" campaign. They should also include
programs devoted to reducing the burden of smoking in communities of
color. They should include the dissemination of "Pathways to Freedom" to
every African American smoker. And they should focus on reducing
disparities in smoking-related disease, not just in reducing the overall
rates of smoking.

Addressing the problem of the nation's budget woes by balancing the
budget on the backs of smokers, in the face of the decimation of the
nation's tobacco control program and the absence of any significant
government-funded services available to benefit smokers (including programs
to encourage kids not to smoke and to help adults to quit), and in the
presence of other viable options for raising the needed revenue such as
taxing the wealthiest of the state's citizens or corporations, is not an appropriate public health policy.

What these anti-smoking groups are calling for is reaping $7 billion a year in additional revenues
from smokers so that the government does not have to take any politically less popular
measures to finance its budget (such as raising taxes on the wealthiest
of citizens and corporations, rather than the poorest residents).

Rather than trying to restore the nation's tobacco prevention and cessation
services, the health groups are essentially acting as accomplices in the
decimation of tobacco control by accepting its demise and not calling for the massive
proposed cigarette tax increase to be used, at least in part, to restore
the program and services.

And this opportunity will not arise
again any time soon. You don't have too many opportunities to raise
taxes these days, so if you are going to do it, you ought to be pretty
darn careful about how you choose to allocate the revenues. If you
aren't spending the money, at least in part, to benefit those who are
shouldering the burden of the payments, then the tax is truly regressive
and discriminatory.

As Dr. Richard Wagner stated in his report critical of the use of tobacco taxes to fund state budget shortfalls: "Tobacco
taxation is a severe form of tax discrimination whose victims reside
primarily among the working classes and not professional people. It is
tax discrimination against people of modest means for the benefit of the
well-to-do."

I think this discriminatory effect can be
mitigated by allocating the revenues from the tax to benefit those who
are paying the tax (such as providing for cessation services, tobacco
prevention programs, smoking education, medical treatment for
smoking-related diseases, and increased research on treatments for the
diseases which we are so dismal in treating). However, this is not what
the health groups are calling for. Instead, they seem content to have
the money used simply to balance the budget, and to allow the decimated
state tobacco control programs to remain in shambles.

The rest of the story is that the actions of these anti-smoking groups is a major victory for the wealthiest corporations and citizens, who are now protected from having to do their share to make
up for the budget shortfall, or misplaced priorities, that denies early childhood education for lower-income children.

Wednesday, October 23, 2013

The headline may sound like a misnomer, but it's actually true. It is four years after the federal government banned the sale of flavored cigarettes, according to the leading anti-smoking groups that boasted about that ban. Yet now, four years later, comes word that 35% of youth smokers are smoking flavored cigarettes. How is that possible?Background

In a press release
issued by FDA when the flavored cigarette ban went
into effect, Commissioner Hamburg stated: "Almost 90 percent of adult smokers start
smoking as teenagers. These flavored cigarettes are a gateway for many
children and young adults to become regular smokers. The FDA will
utilize regulatory authority to reduce the burden of illness and death
caused by tobacco products to enhance our Nation's public health."

In
the same press release, Assistant Secretary of Health and Human
Services Dr. Howard K. Koh also asserted that flavored cigarettes are
causing youth to become addicted to tobacco and that the flavored
cigarette ban would help prevent nearly 3,600 youths a day from becoming
addicted. In the press release, Dr. Koh stated: "Flavored cigarettes
attract and allure kids into lifetime addiction. FDA's ban on these
cigarettes will break that cycle for the more than 3,600 young people
who start smoking daily."

Even more recently, Representative Henry Waxman also asserted that candy-flavored cigarettes
are used by the tobacco industry to hook teenagers on cigarettes. He stated:
"On the first anniversary of the historic Family Smoking Prevention
and Tobacco Control Act, it is important to focus on the crucial
protections and benefits the law has provided, and the additional
safeguards due to take effect today. The new law gave the Food and Drug
Administration (FDA) authority to regulate tobacco products, as well as
their advertising and marketing. Using this new authority, FDA banned
candy- and fruit-flavored cigarettes, used by the tobacco industry to
hook children on tobacco."

The Truth

The truth, according to the recent CDC report, is that "35.4 percent of current youth cigarette smokers reported using flavored cigarettes."

The Rest of the Story

Clearly, Commissioner Hamburg, Assistant Secretary Koh, and Representative Waxman were lying to us. They were pulling the wool over our eyes, trying to make us think that the 2009 federal tobacco law would end the scourge of teenage addiction to flavored cigarettes. Alas, that was a lie. Here we are four years later and we find out that teen smokers are very bit as much addicted to flavored cigarettes as they were in 2009. What gives?

What gives is the honesty and integrity of the anti-smoking movement, its major organizations, and politicians who pretended to be champions of the public's health in supporting the earth-shattering Family Smoking Prevention and Tobacco Control Act of 2009 with its "critical protections" for our nation's youth.

The rest of the story is that rather than addressing the problem of the 3,600 youths a day who become addicted to smoking, the legislation instead was filled with window dressing. Instead of banning the one flavoring that about half of these youths were actually using, the Tobacco Act banned a host of candy flavorings that were being used by almost nobody. This gave the anti-smoking organizations and politicians the opportunity to pretend that they really cared about youth smoking addiction but without actually having to take a politically courageous act.

It is almost comical, then, to today see the Campaign for Tobacco-Free Kids complain about the 35% of youth smokers using menthol cigarettes, and call for a menthol ban. What the Campaign doesn't tell you in its statement is that it was the Campaign for Tobacco-Free Kids itself which was responsible for the failure of the Tobacco Act to ban menthol. Not only was the Campaign instrumental in crafting the legislation - which exempted menthol - but the Campaign actually opposed an amendment that would have removed the menthol exemption.

The Campaign's statement concludes: "Today’s study should prompt the FDA to act quickly to stop the tobacco
industry from using flavored products to addict children and put them on
a path to serious diseases and premature death." That is a bunch of crap, because if the Campaign for Tobacco-Free Kids had really wanted to act quickly to stop the tobacco industry from using flavored products to addict children and put them on a path to serious diseases and premature death, then it would have supported, rather than opposed the amendment to remove the menthol exemption from the legislation.

Tuesday, October 22, 2013

If you think you read that headline incorrectly, there's no need to read it again. You did read it right.

In a statement that would immediately result in a racketeering and fraud lawsuit against any tobacco company making it, a tobacco control practitioner - of all people - has told the public that cigarettes may have fewer chemicals and carcinogens than electronic cigarettes.

The tobacco practitioner, who is the tobacco control program coordinator for the Southern Nevada Health District, also told the public that smoking may be no more hazardous than vaping a non-tobacco, non-combusted electronic cigarette.

That's another statement that would bring an immediate racketeering and fraud charge if made by a tobacco company.

"Maria
Azzarelli, the tobacco-control program coordinator for the Southern
Nevada Health District, believes e-cigarettes are threatening decades of
anti-smoking campaigns that have changed social norms and perceptions
about smoking. ... “At the end of the day, we want people not to get addicted to nicotine,”
Azzarelli said. “No one can say right now whether e-cigarettes are a
healthier alternative to cigarettes or hookah.” ... “The tobacco industry is taking everything out of their playbook and
recycling it because it works,” Azzarelli said. “After lying for decades
about carcinogens in cigarettes, are we going to trust the tobacco
industry when they say e-cigarettes are safe?” ... “Right now, there needs to be more research,” Azzarelli said. “We need
legitimate studies on these things to see if they have fewer chemicals
and carcinogens than cigarettes. We need to know more.”"

The Rest of the Story

Let's take a look at each of the three claims that are being made:

1. Cigarettes may contain fewer chemicals than electronic cigarettes.

This is blatantly false. Electronic cigarettes have been extensively tested and the cartridges generally contain about four to six chemicals: nicotine, propylene glycol, glycerin, and flavorings. Electronic cigarette vapor has also been extensively tested and it contains approximately 10 to 20 chemicals. In contrast, cigarette smoke contains between 10,000 and 100,000 chemicals, of which about 6,000 have been identified.

It is therefore fraudulent to suggest that cigarettes may contain fewer chemicals than electronic cigarettes.

This is also blatantly false. Electronic cigarettes have been extensively tested and the vapor contains detectable levels of about one to five carcinogens. In contrast, cigarette smoke contain more than 60 known human carcinogens.

It is therefore fraudulent to suggest that cigarettes may contain fewer carcinogens than electronic cigarettes.

3. Cigarettes may be no more hazardous than vaping.

Numerous studies have shown that electronic cigarettes greatly reduce the carcinogenic risks associated with tobacco smoking as well as the lung disease risks. There is initial evidence that electronic cigarettes also convey a lower risk of heart and vascular disease. There is no question that many vapers who switch from tobacco cigarettes to electronic cigarettes experience an immediate reduction in respiratory symptoms and an improvement in their health.

It is therefore fraudulent to suggest that cigarette smoking may be no more hazardous than vaping.

I cannot honestly recall a situation in the past in which public health practitioners were lying almost every day to the public about a particular health issue. We're reaching the point where not a day goes by without anti-smoking advocates somewhere disseminating false or fraudulent information to the public about electronic cigarettes.

Once again, I believe this need to lie to the public is a result of the ideology in the anti-smoking movement, in which there is simply not room for a behavior that looks like
smoking to possibly have positive features or benefits. I believe that
concept is just too difficult for anti-smoking organizations to accept. Rather than deal with the facts, then, they have to fabricate information that comports with their ideological life-view.

Ironically, the anti-smoking advocate in this article complains that: "After lying for decades
about carcinogens in cigarettes, are we going to trust the tobacco
industry when they say e-cigarettes are safe?" Sadly, the rest of the story is that it is not the tobacco industry which is lying now. It is the anti-smoking advocates, especially ones like this who are actually telling the public that cigarette smoking may be no more harmful than vaping.

Monday, October 21, 2013

According to an op-ed piece by the American Lung Association (ALA) published last Thursday, the tobacco industry is marketing electronic cigarettes to kids by enticing them with sweet flavors, including cotton candy, atomic fireball, and gummy bear.

According to the ALA: "E-cigarette use among middle school children has doubled in just one
year. ... Yet, the Food and Drug Administration
(FDA) still is not regulating e-cigarettes. The absence of regulatory
oversight means the tobacco industry is free to promote Atomic Fireball
or cotton candy-flavored e-cigarettes to our children. ... Big
Tobacco is happy to hook children with a gummy bear-flavored
e-cigarette ... ."

The American Lung Association, then, is claiming that Big Tobacco companies are marketing the following electronic cigarette flavors to children:

1. Atomic Fireball
2. Cotton Candy
3. Gummy Bear

The Rest of the Story

The rest of the story is quite simple. The American Lung Association's claim is fraudulent. The ALA is lying in order to create an alarming story that simply doesn't exist. Why would the ALA open itself up to a lawsuit from Big Tobacco by making fraudulent claims about these companies' marketing practices? Apparently, the ALA must perceive that the truth is simply too damaging to reveal to the public.

Here is the truth:

Fact #1: None of the U.S. tobacco companies that sell electronic cigarettes market disposable products in flavors other than tobacco (classic) or menthol. Note that the disposable products are the ones that are relevant to children because they are the cheapest and most likely to be used by kids. It is very unlikely that kids are going to unleash the money required to purchase the charging kit. Blu offers rechargeable starter kits that do contain flavorings, but
does not offer atomic fireball, cotton candy, or gummy bear. However, kids would have to shell out a minimum of $70 for the starter kit.

Here are the available electronic cigarette flavors offered by Big Tobacco:

Fact #2: In contrast to the ALA's assertion, the Big Tobacco companies are actively avoiding the marketing of candy-flavored electronic cigarettes to children.

Philip Morris and R.J. Reynolds are only offering original and menthol flavors.

Lorillard is not offering candy-flavored disposable electronic cigarettes. This is perhaps the clearest signal that the tobacco companies are not marketing flavors to children. It should be obvious to the American Lung Association, if they put any thought into their op-ed piece, that the best way to judge Lorillard's intentions is to examine the differences between their starter kit flavors (the ones which require you to shell out 70 bucks) and their disposable flavors (the ones which kids are most likely to use). In fact, while the starter kit flavors do include candy varieties, the disposables do not. This is a clear sign that Lorillard is not interested in offering candy-flavored electronic cigarettes to the youth market.

In fact, Blu was already offering these candy-flavored varieties prior to its acquisition by Lorillard. It is understandable while Lorillard maintained these flavors, since it wouldn't want to lose existing Blu customers. But it is telling that Lorillard chose not to extend this candy-flavored approach over to its disposable e-cigarette segment. If the ALA's assertion were correct, then Lorillard would most certainly be selling candy-flavored disposable electronic cigarettes.

So the rest of the story is that:

1. Big Tobacco is not "happy to hook children with a gummy bear-flavored e-cigarette."

Why this apparent need to lie? Perhaps it is because the truth is too inconvenient for the American Lung Association to accept. The truth is that rather than "forging a new pathway to addiction, death and disease," as the op-ed's title suggests, electronic cigarettes are doing exactly the opposite. They are helping smokers break their addiction to cigarettes and thereby preventing death and disease.

Why would this fact be "inconvenient" or "damaging" for the American Lung Association? I believe it is because the ideology in the ALA is so strong that there is simply not room in its mindset for a behavior that looks like smoking to possibly have positive features or benefits. I believe that concept is just too difficult for the ALA to accept. They are not alone. I believe that most anti-smoking groups are not prepared or able to face this fact.

This is one situation where I think it is safe to say: "The American Lung Association cannot handle the truth."

Wednesday, October 16, 2013

Starting next year, the use of smokeless tobacco and the use of electronic cigarettes will not be allowed anywhere on University of California property. These bans will accompany a ban on the use of cigarettes and all other tobacco products on the 10 campuses in the UC system.

According to an article in the Daily Nexus: "UCSB is currently making the shift to going totally
smoke-and-tobacco-free, as all universities in the 10-campus UC system
will be officially designated as non-smoking beginning Jan. 1, 2014. On the first day of the new year, any tobacco and tobacco-free
products smoked through cigarettes, pipes, water pipes and hookahs used
on campus — in addition to smokeless tobacco and unregulated nicotine
products such as “e-cigarettes” — will be in violation of the
policy. Adoption of the policy will join the UC with 1,100 other
colleges and universities throughout the U.S. that have already
implemented such regulations to limit second and third-hand smoke
exposure on campus. The UC system’s transition to becoming completely
smoke and tobacco-free was first announced by former UC President Mark
G. Yudof back in January 2012."

The Rest of the Story

This policy makes little sense. First of all, while I recognize the need to protect nonsmokers from secondhand smoke exposure, it hardly seems necessary to ban smoking everywhere on the entire campus to accomplish this goal. Banning smoking in all indoor areas, in outdoor areas where people congregate or cannot easily avoid exposure, and within a reasonable distance of doors and entrance ways seems reasonable. But it is not necessary to completely ban smoking, even in private cars and remote areas of parking lots and open fields, in order to adequately protect nonsmokers from secondhand smoke.

Second, even if we acknowledge a rationale for banning smoking, why would we want to also ban electronic cigarette use? The overwhelming majority of smokers who use electronic cigarettes are trying to quit smoking. Why would we want to deter this? Why punish these smokers for making a wonderful health decision? Why provide a disincentive for smokers to quit, while providing an incentive for them to return to cigarette use? How does this make any kind of health statement?

Third, while banning smoking protects the health of others, banning smokeless tobacco use is purely paternalistic. But if the university is going to set paternalistic policies to protect students' health, then how can it ban smokeless tobacco use but not alcohol use? To be sure, alcohol will cause more death and destruction on these university campuses than smokeless tobacco. Even worse, by banning smokeless tobacco but leaving alcohol untouched, these policies represent the worst form of hypocrisy.

You either decide to promote a healthy campus or you don't. And if you believe that promoting a healthy campus means being paternalistic and regulating the behaviors that people can or cannot do (even if they don't affect others), then you can't be selective and just cut out the behaviors that you personally don't approve of.

The rest of the story is that the UC smoke-free policy reeks of hypocrisy, intolerance, and moral judgment of others. It is by no means a public health policy. Instead, it is a statement of a warped ideology, by which getting drunk is fine, but using a little dip is not, and by which trying to quit smoking via hypnosis is A-OK, but trying to quit using electronic cigarettes is a no-no.

Tuesday, October 15, 2013

In a campaign of deception, tobacco control practitioners throughout the country continue to spread both misleading and outright false information about the health issues regarding electronic cigarettes.

Here are just a few examples from recent days:

1. A tobacco control practitioner in Indiana claimed that we don't know what is in electronic cigarette vapor. Another tobacco control practitioner, from Illinois, claimed that there's no evidence that electronic cigarettes can help people stop smoking.

According to an article in the Princeton Daily Clarion: "E-cigarette supporters claim it can help smokers on the road to
becoming smoke free, but Gwen Siekman, the Coordinator for a Tobacco
Free Gibson County, says that e-cigarette smokers are just trading one
addiction for another." ...

"“They are totally unregulated and they are very
scary,” Siekman said. Supporters of the e-cig say there’s no secondhand
smoke that will affect non-smokers around them, but Siekman said, “They
don’t know what that vapor has in it.”"

"Ronda Hockgeiger, Wabash County Health
Department’s prevention coordinator, said that there’s no new evidence
that e-cigarettes help people stop smoking." ...

"Siekman is adamant that people should not use e-cigarette to quit smoking."

2. A tobacco control practitioner in Florida was quoted as stating that "we don't know the long-term effects of inhaling that nicotine solution,
all day, every day, for years. So we don't know if they're
safer than tobacco. The research hasn't been done."

3. A Utah tobacco control practitioner claimed that smokers who use cigarettes and electronic cigarettes increase their nicotine consumption: "smoking cigarettes and e-cigarettes leads to increased nicotine consumption."

4. A Florida physician and tobacco control advocate published an op-ed piece, in which he argued that the idea of using electronic cigarettes for harm reduction is not a public health approach, but simply a marketing strategy: "My first concern is over the
concept of Tobacco Harm Reduction, or THR as those promoting
e-cigarettes like to call it. They frequently question why physicians
would be against a product that might reduce the risks posed by
traditional tobacco products. I am against THR because it is a marketing strategy, not a public health policy."

The Rest of the Story

All of these tobacco control practitioners are spreading misleading and/or false information about electronic cigarettes. And this is just from the past several days. The amount of inaccurate information being disseminated by tobacco control groups throughout the country is alarming. It is also very damaging because it misleads the public and hides the truth. The net effect is to undermine the public's appreciation of the hazards of cigarette smoking.

Let's take the lies one by one.

First, it is not true that we have no idea what is in electronic cigarette vapor. These products have been extensively studied and we have a fairly good idea what is in there. The difficulty is not that we are unaware of the vapor constituents; the problem is that it is difficult to project the long-term risks of inhalation of small levels of a chemical like formaldehyde or acrolein. But we actually have a much better idea what is in electronic cigarette vapor than what is in tobacco smoke.

Second, it is not true that we don't know whether vaping is safer than smoking. Even tobacco companies would not argue that smoking is no more dangerous than vaping. It doesn't take rocket toxicology to figure out that inhaling nicotine plus tens of thousands of chemicals including more than 60 known carcinogens is going to be more dangerous than inhaling nicotine plus low levels of a few chemicals. It doesn't take rocket epidemiology to figure out that burning tobacco is going to result in a more dangerous product than heating nicotine dissolved in propylene glycol and glycerin. tobacco companies don't argue that smoking may be no more dangerous than vaping. Why would a public health advocate advance such an argument?

Third, it is not true that dual users of electronic cigarettes and regular cigarettes increase their nicotine consumption. Actually, smokers who substitute electronic cigarettes for regular ones decrease their nicotine consumption because the electronic cigarette is nowhere close to a tobacco cigarette in its ability to deliver nicotine. The overwhelming majority of electronic cigarette users are lowering their nicotine consumption, even if they maintain dual use of both products.

Fourth, it is not true that the idea of using electronic cigarettes for harm reduction is simply a marketing strategy. Vaping is much safer than smoking, and smokers who have been able to quit using electronic cigarettes have likely saved their lives. This is a bona fide public health strategy that could literally transform the tobacco epidemic. Other examples of harm reduction strategies in public health are needle exchange programs, methadone programs, and comprehensive sex education. Are those also merely marketing strategies?

In addition to spreading lies and misinformation, these tobacco control practitioners (and hundreds like them throughout the country - these are just a few recent examples of what I am reading literally every day in newspapers nationwide) are providing damaging and inappropriate advice: telling smokers not to quit smoking using electronic cigarettes. This is terrible advice. If a smoker is able to quit, we should be congratulating that person, not attacking them or telling them that they did something wrong and are endangering their health. It's quite the opposite.

To my mind, publicly advising smokers who are or may be able to quit using electronic cigarettes not to quit using these products is tantamount to committing public health malpractice on a grand scale.

Thursday, October 10, 2013

On his blog yesterday, Dr. Stan Glantz announced that there is "more evidence that e-cigarettes inhibit quitting conventional cigarettes."

I was intrigued by this claim because if true, it would discount much of what I have been doing for the past few years (i.e., supporting electronic cigarettes as a bona fide strategy for quitting smoking). Not only is Dr. Glantz arguing that electronic cigarettes are ineffective; he is arguing that they actually inhibit quitting.

So naturally, I was very curious to read the actual study that Dr. Glantz was citing to provide this evidence that electronic cigarettes inhibit quitting.

The study he cited is entitled "Alternative Tobacco Product Use and Smoking Cessation: A National Study."

Here is what Dr. Glantz tells us about the study, which he says provides evidence that electronic cigarettes inhibit smoking cessation: "Ever use of e-cigarettes was not associated with being a successful
quitter (OR 1.09; 95% CI 0.72-1.65) but was associated with being an
unsuccessful quitter (OR=1.78, 95% CI 1.25-2.53) compared to people who
had never tried to quit."

Dr. Glantz concludes that the evidence from this study "adds to the case that the loudly made claims that e-cigs help smokers quit are wrong."

The Rest of the Story

The truth is that this study adds absolutely no evidence about the effectiveness of electronic cigarettes. The study was not designed to examine the effectiveness of electronic cigarettes. In fact, it was simply a cross-sectional study that investigated the prevalence of ever use of e-cigarettes among a sample of current and former smokers.

To determine whether electronic cigarettes are effective for smoking cessation, one would have to study smokers in a longitudinal fashion. You would want to compare a sample of smokers who used electronic cigarettes to try to quit with smokers who did not use electronic cigarettes to try to quit. Ideally, one would randomize smokers into these two groups, and compare the effectiveness of electronic cigarettes with a different approach such as the nicotine patch or gum.

But that's not what this study did at all. It simply measured ever use of electronic cigarettes among smokers and former smokers at a single point in time. The survey provided no information about whether the smokers used electronic cigarettes in an attempt to quit smoking. It provided no information about the timing of their electronic cigarette use. It provided no information about whether they actually used electronic cigarettes regularly or whether they merely tried the product on a single occasion to see what it was like.

Most importantly, because the study is cross-sectional, it cannot tell us which came first. Did electronic cigarettes cause people to be unsuccessful quitters, or is it the case that people use electronic cigarettes because they are having trouble quitting?

In fact, we know from other research that the latter is true. The majority of smokers who try electronic cigarettes are trying these products specifically because they have failed to quit using other means, such as nicotine replacement therapy. So it is in fact no surprising to find that the use of electronic cigarettes is high among people who have not succeeded in quitting smoking.

To be blunt, if one of my students argued in a paper that this study provides evidence that electronic cigarettes inhibit smoking cessation, I couldn't give the paper a passing grade.

In fact, the very authors of the article make it clear that the results of this study cannot be used to infer that electronic cigarettes inhibit smoking cessation. They write:

"Because this was a cross-sectional study, we could not determine whether use of alternative tobacco products resulted in cessation attempts or whether those who were trying to quit--for whatever reason--were using alternative tobacco products. We also could not determine whether use of these products is intended to facilitate quitting and whether use leads to successful quitting. Prospective longitudinal studies should examine whether smokers who use smokeless tobacco are actually more successful at quitting."More to the Rest of the Story

The story doesn't end here.

In the same blog post, Dr. Glantz cites another study which he argues provides evidence that electronic cigarettes inhibit quitting. According to Dr. Glantz, this study showed "lower quit rates for e-cig users."

The rest of the story is that this study didn't actually measure quit rates among smokers using electronic cigarettes in an attempt to quit smoking. What Dr. Glantz does not reveal is that instead of estimating
cessation rates among a cohort of smokers who made quit attempts using
these products, the study analyzed cessation rates of a large number of
smokers who had previously tried to quit using e-cigarettes but failed,
and then called a quitline because they had failed and wanted to try
again.
Then, they compared the quit rate among these smokers to that among
smokers without such a history of a failed quit attempt using electronic
cigarettes.

In other words, this study did not estimate quit rates among smokers
trying to quit using e-cigarettes. Instead, it estimated quit rates
among many smokers who were not using e-cigarettes in their quit attempt
at all!

The truth is that many of the electronic cigarette users in the study did not use electronic cigarettes in their quit attempts!
According to data provided in the paper, a full 28% of the sample of
electronic cigarettes did not use these products in their quit attempts.

It should be clear to readers that this study was poorly designed to
investigate the efficacy of electronic cigarettes. The study systematically
sampled a group of quitline callers who were unsuccessful using electronic
cigarettes. These people tried and failed using electronic cigarettes. How do
we know they failed? Because they wouldn’t have had to call the quitline if
they weren’t still smoking. This is clearly a harder core group of smokers and
it is no surprise that their cessation rates were lower after 6-months than the
comparison group. The study tells us nothing about the effectiveness of
electronic cigarettes, other than that they do not work for everyone. Any researcher sincerely interested
in testing the efficacy of electronic cigarettes would not test the research
question in this way. If the tobacco industry conducted precisely this same study in order to
conclude that electronic cigarettes are ineffective as a smoking
cessation tool, we would call it scientific fraud.

Moreover, the authors of this study, like those of the one discussed above, explicitly stated that the results cannot be used to evaluate the effectiveness of electronic cigarettes for smoking cessation and that the study was not designed for that purpose. Concerned that Dr. Glantz was misrepresenting the results of their study, the authors of the study - who are at Alere Wellbeing
- publicly admitted that the study was never intended to assess the
effectiveness of electronic cigarettes and that the data should not be
used for this purpose.

The Alere Wellbeing blog states very clearly: "The recently published article by Dr. Katrina Vickerman and colleagues has been misinterpreted by many who have written about it. It was never intended to assess the effectiveness of the e-cig as a mechanism to quit."

Dr. Vickerman herself explained
that her results do not in any way indicate that electronic cigarettes
are less effective than NRT, stating: "It may be that callers who had
struggled to quit in the past were more
likely to try e-cigarettes as a new method to help them quit. These
callers may have had a more difficult time quitting, regardless
of their e-cigarette use."

This is a study that Dr. Glantz called a "good study" on "the use of e-cigs for cessation."

If this is a "good study" on the use of e-cigs for cessation, I'd like to see a bad one.

Conclusion

As my readers know, Dr. Glantz was and is a hero to me. He was a mentor for my career in tobacco control. He set an example to me for the use of science for advocacy purposes. He still is way ahead of the rest of the tobacco control movement in seeing the field and the direction it needs to go. He has always been the person who I considered to be the leader of the movement. However, it appears to me that Dr. Glantz - for some reason - is determined to oppose electronic cigarettes, regardless of the actual scientific evidence. He is grasping at straws, trying to find any shred of evidence - whether valid or not - to support his contention, apparently a pre-determined one, that electronic cigarettes are making it more difficult for smokers to quit.

There are literally tens of thousands of former smokers out there who will find this a joke, as they successfully quit thanks to electronic cigarettes. Moreover, an actual clinical trial which did measure quitting among smokers in a longitudinal fashion and did randomize smokers to NRT vs. e-cigarettes, found that electronic cigarettes are every bit as effective as the nicotine patch for smoking cessation. In the light of that evidence, how can Dr. Glantz continue to argue that electronic cigarettes inhibit smoking cessation?

My opinion is that much like the rest of the anti-smoking movement, Dr. Glantz is so blinded by ideology that he cannot bring himself to condone a behavior that looks like smoking, regardless of what the evidence shows or the experience of vapers tells us.

Ideology is not necessarily a bad thing. In fact, the strong ideology in the anti-smoking movement is probably what helped it to become such a strong and successful movement. But at some point, you need to be able to critically evaluate scientific evidence without the cloud of ideology. One can still be a passionate advocate without losing scientific integrity. Sadly, we have reached the point where the anti-smoking movement has lost its ability to do that. The ideology has become so dominant that it is drowning out the rigorous scientific analysis that I believe used to guide the movement.

Wednesday, October 09, 2013

The EU parliament has rejected the provisions of the Tobacco Product Directive that would have regulated electronic cigarettes as drugs, thus essentially removing them from the market or making it extremely difficult for them to compete as an alternative to real cigarettes.

According to an article in the Globe and Mail: "Legislators also voted for new limits on advertising for electronic
cigarettes, but rejected a measure that would have restricted them to
medical use only. The battery-operated products, which are enjoying a
boom in the United States and many European countries, turn nicotine
into a vapour inhaled by the user and are often marketed as a less
harmful alternative to tobacco. Many health experts say e-cigarettes are
useful for people trying to quit or cut down on nicotine."

"Armando
Peruga, a tobacco control expert at WHO in Geneva, said regulating
e-cigarettes wouldn’t necessarily be a bad thing and that WHO is
currently evaluating their safety and effectiveness. “We do think
e-cigarettes could be useful, but we need more information. We have not
yet ruled them out. We do think they could be helpful for some smokers.”"

The Rest of the Story

The tide is starting to turn, as evidenced not only by the EU Parliament's decision to allow electronic cigarettes to compete with tobacco cigarettes, but also by the complete change in the WHO's position on these products. The WHO had previously blasted electronic cigarettes and recommended strongly against their use. Now, however, the WHO actually opines that electronic cigarettes could be helpful for some smokers.

What caused this turn of events and the turning of the tide regarding opinion on electronic cigarettes?

The answer is ...

... the vaping community.

It is the actual users of these products who are responsible for the changing attitudes toward electronic cigarettes, including the EU Parliament's rejection of the de facto e-cigarette ban and the WHO's change of heart on e-cigarettes.

The voices of the actual people who use these products have drowned out the ideological hysteria of anti-smoking groups and officials.

The vaping community is to be congratulated because it has been successful in building a movement in which its voice can be heard. The many vaping forums, advocacy actions, and advocacy groups, and the public presence of vapers has made the difference by showing policy makers that while anti-smoking groups continue to talk about theoretical people who don't exist, there are tens of thousands of people who do exist and who are benefiting from these products.

This reminds me of a pet peeve of mine. I hate when I'm sitting in a restaurant waiting for a long time to be served and the restaurant staff is busy setting the other tables for people who have not yet arrived. While they meticulously set the table for hypothetical customers who may or may not arrive, there are actual customers in the establishment right now who need service.

The anti-smoking groups are acting like those restaurant staff. While they use scare-mongering to get policy makers to worry about the hypothetical people who don't yet exist - smokers who would otherwise quit if not for e-cigarettes and youth smokers who initiated because of e-cigarette use - they are ignoring the tens of thousands of people who have improved their health and possibly saved their lives because of electronic cigarettes.

Fortunately, hearing from actual people who have benefited from these products is drowning out the complaints of anti-smoking groups about the hypothetical possibilities that have not yet occurred. Nearly every proposed ban on electronic cigarettes has so far been defeated, largely because the vaping community has spoken out and when policy makers have heard what these products are doing for smokers, they have seen the light and decided not to restrict the ability of these ex-smokers to remain ex-smokers.

Has the FDA also heard the voices of the vaping community? We'll find out momentarily, as the proposed regulations should be released shortly.

In the meantime, the vaping community should take time to celebrate its accomplishments. It has overcome quite a formidable lobby, one that for some reason has forsaken the public's health to ensure that society does not condone a behavior that looks like smoking, even though it is saving lives.

Tuesday, October 08, 2013

Recently updated data from the Smoking Toolkit Study demonstrate that there has been a striking increase in the rate of quit attempts in England during the past two years, and that this increase is associated with a dramatic rise in the use of electronic cigarettes. These data suggest that the proliferation of electronic cigarettes in England is the reason for the marked increase in smoking cessation attempts.

The proportion of cigarette smokers using electronic cigarettes rose dramatically in England from 2% in May 2011 to 16% in August 2013. Associated with this proliferation of electronic cigarettes was:

(1) an increase in the percentage of smokers making quit attempts; and
(2) an increase in the percentage of smokers who reported being motivated to quit smoking (i.e., intending to stop smoking soon).

While these quit attempts do not appear to have yet resulted in a demonstrable decline in the prevalence of cigarette smoking, one would expect to observe such a decline with sustained follow-up, as increased quit attempts and increased motivation to quit are known to be associated with rates of successful cessation.

While these data do not prove that the use of electronic cigarettes is what caused the increase in quit attempts, the dramatic nature of the increase in both phenomena and the timing of these changes strongly suggests that what we are observing is an effect of electronic cigarette use.

The Rest of the Story
These data suggest another potential advantage of electronic cigarettes: it is possible that they stimulate quit attempts. Independent of their potential effectiveness in helping smokers quit, if these products lead to an increased proportion of smokers trying to quit, they would be expected to have a positive public health impact.

These data add to the existing evidence which suggests that electronic cigarettes are having significant public health benefits by stimulating and facilitating smoking cessation. While they are no wonder drug, they appear to be at least as effective as nicotine replacement products and to offer hope to millions of smokers who have been unsuccessful using the FDA-approved smoking cessation products.

Surprisingly, anti-smoking researchers and groups continue to advocate against electronic cigarettes and refuse to acknowledge the overwhelming evidence that these products are indeed helping thousands of smokers to stay off cigarettes.

The two potential drawbacks of electronic cigarettes - that they could inhibit complete nicotine cessation in smokers who would otherwise have achieved that and that they will be a gateway to smoking among youth - do not appear to be of concern at the present time. There is no evidence that either phenomenon is occurring. Most electronic cigarette users are trying these products specifically because they have failed with other approaches. So these are not smokers who would miraculously quit completely if only electronic cigarettes were not available. Neither is there any evidence that these products are starter products for youth who then go on to initiate smoking.

Thus, at the present time, it appears that electronic cigarettes are having a substantial net positive effect on the public's health. Yet anti-smoking groups continue to discourage this approach. Fortunately, there is a limit to how long these groups can continue to deny the overwhelming evidence.

Monday, October 07, 2013

In 2009, several "anti-smoking" groups attempted to get electronic cigarettes pulled from the market. The major organizations that lobbied for a ban on electronic cigarettes were the Campaign for Tobacco-Free Kids, American Cancer Society, American Lung Association, and American Heart Association.

The Rest of the Story

It is important to recognize that if these organizations had succeeded, there would be tens of thousands more cigarette smokers today. There are tens of thousands of former smokers in the United States who would not have quit smoking had electronic cigarettes been pulled from the market as recommended by these "anti-smoking" groups.

Imagine the increase in disease that would have resulted had the advice of these groups been followed. Imagine the increase in sales of cigarettes and profits for Big Tobacco.

In light of these facts, it is difficult to understand how these organizations can continue to be referred to as "anti-smoking" groups. Their suggested actions would have resulted in tens of thousands more cigarette smokers.

The rest of the story is that rather than stand up to protect the public's health, these groups were so blinded by ideology that they instead promoted public policy that would have protected Big Tobacco sales and profits at the expense of the public's health.

In light of this, I call upon these organizations to acknowledge their error and to apologize to the tens of thousands of former smokers who would likely still be smoking today if the policy that these groups lobbied for had been adopted.

(The Consumer Advocates for Smoke-free Alternatives Association [CASAA] expresses a similar sentiment in a recent blog post.)

Thursday, October 03, 2013

The Rest of the Story has obtained the password and a copy of a password-protected link to a new e-cigarette television commercial for R.J. Reynolds Vapor's innovative product - Vuse - which is being test-marketed in Colorado. The link and password circulated among anti-tobacco researchers and advocates after one of them violated an agreement with a news reporter to keep the information confidential. The anti-tobacco advocates had an email exchange roundly attacking the commercial, and two of them argued that this advertising will entice former smokers to return to cigarette smoking. The ad was called "cool" and "slick" and was compared to cigarette advertising.

The Rest of the Story

After receiving the link and password, and having read the attacks against the ad, I was fully expecting to view a commercial that glamorized cigarette smoking and promoted cigarette use through the guise of pretending to want people to use electronic cigarettes.

Instead, what I found was quite the opposite: a commercial that actually advocated the idea of getting rid of conventional cigarettes and replacing them with a much safer product that contains no tobacco.

The commercial focused on the idea of innovation. Specifically, the innovation it talked about was the transformation of the entire cigarette market: a transformation from deadly cigarettes to these much safer electronic ones. The campaign is backed by print materials that focus on the idea of reducing the harm caused by smoking by getting smokers to use electronic cigarettes instead of conventional ones.

Nowhere in the ad or the campaign is there any suggestion that the intention is to promote dual use of cigarettes and electronic cigarettes, and nowhere in the ad or the campaign is there any suggestion that the product is aimed at recruiting youth or adult nonsmokers.

Frankly, I was shocked to see a cigarette company make the clear admission that its products are harmful and that it would advance the public's health to promote the idea of smokers switching to a non-tobacco, non-combustion product that is orders of magnitude safer. I was especially shocked after reading the vicious criticism of the commercial and the claims that it would attract youth as well as former smokers to start smoking. If this commercial was a veiled attempt to attract nonsmokers or former smokers to cigarette smoking, it was a miserable failure.

I thought the commercial could have been more effective only if it explicitly promoted smoking cessation. However, RJR Vapor is clearly not going to make such a claim because of the danger of the FDA interpreting that as a drug claim and pulling the product off the market on that ground. As I've argued previously, the FDA deeming regulations need to make it clear that the FDA will allow smoking cessation claims that are not based on treatment of nicotine dependence and will not treat such claims as therapeutic claims. This would go a long way toward helping ensure that e-cigarette advertising does not in any way promote cigarette smoking or the use of e-cigarettes by nonsmokers.

Recently, I have heard a lot of arguments by anti-smoking advocates that e-cigarette advertising glamorizes and promotes smoking. The problem is that these ads are not selling cigarettes. They are selling e-cigarettes. What they glamorize is not smoking, but vaping. These arguments make absolutely no sense.

Incidentally, the commercial did not depict the act of smoking or even vaping. It focused on the product, the technology, the taste, the innovation, and the transformation of the market.

The final aspect of this story is the tactics being used. Regardless of the worthiness of our cause, I don't believe that as health professionals, we should act in a dishonest way. There was a violation of the agreement made with the reporter. The private, password-protected site was shared with 21 tobacco control advocates, including several government officials. The commercial was eventually released publicly, but this unauthorized distribution of the spot preceded its public release.

It is difficult to imagine what more RJR Vapor could have done to target this commercial to adult smokers. The spot makes it very clear that the product is for smokers. It talks about transforming the cigarette market by shifting to electronic cigarettes. It seems to me that this is something that we should be applauding, rather than attacking.

Wednesday, October 02, 2013

From November 25 to 27, tobacco control practitioners from Canada will gather in Ottawa for the 8th National Conference on Tobacco or Health. While the conference purports to promote an objective consideration of research evidence in tobacco control, the truth is that the conference organizers have already sold out the scientific integrity of the conference by accepting its sponsorship by Big Pharma. Specifically, Johnson & Johnson, Inc. will be a major sponsor of the conference. Johnson & Johnson's products include Nicorette - a nicotine replacement drug, in the form of gum or lozenges.

The Rest of the Story

The mystery as to why so many anti-smoking groups oppose electronic cigarettes becomes a little less mysterious.

Today's story illustrates the entrenched financial position of Big Pharma in the tobacco control movement. By accepting these sponsorships as the financial backbone for the movement, we have corrupted our science and become beholden to the pharmaceutical companies.

Therefore, it is no surprise that our groups are unable to support a product that is the most "worrisome" competitor to the sales of nicotine replacement products, even though it is saving many lives.

No wonder the ideology is triumphing over the science. No wonder that anti-smoking groups don't seem to care about the scientific evidence.

Tuesday, October 01, 2013

For many months, anti-smoking groups have been refusing to acknowledge the experience of literally thousands of vapers: that electronic cigarettes can be helpful in smoking cessation. How have they justified this refusal to acknowledge the facts? Simple. By arguing that no clinical trials have been conducted on electronic cigarettes.

Now that a clinical trial on the effectiveness of electronic cigarettes has been published (it reported that electronic cigarettes were as effective for smoking cessation as nicotine replacement therapy), have the anti-smoking groups changed their tune?

Sadly, the answer is no. Many of these groups are simply ignoring the evidence and continuing to argue that there have been no clinical trials on electronic cigarettes.

For example, according to an article published three days ago in the Pioneer Press, an anti-smoking group in Minnesota continues to argue that there are no clinical trials and that evidence of the effectiveness of electronic cigarettes is based solely on anecdotal evidence.

According to the article: "While the FDA considers
regulating e-cigarettes, states, counties and local governments are
taking the matter into their own hands. Chris Turner, program and media specialist for the Association
for Nonsmokers-Minnesota, said Minnesota is one of the few states that
regulate e-cigarettes, which are treated like tobacco products when it
comes to sale to minors. While e-cigarettes are being hailed by some as safer than
cigarettes, Turner said there are still health concerns. She cited an
FDA study that showed traces of toxic chemicals and the presence of
nicotine even in e-cigarette cartridges that claimed zero nicotine.
'The main thing is they have not been proven safe and have not
been proven effective in helping people quit in terms of clinical
trials,' Turner said. 'What you're seeing now is anecdotal -- people are
saying these are helping them smoke less, but studies have not shown
that.'"

The Rest of the Story

What Turner is asserting is not true. Studies have shown that electronic cigarettes can help many smokers to smoke less or to quit smoking entirely. In a trial conducted among smokers who wanted to quit, electronic cigarettes were as effective as nicotine replacement therapy for smoking cessation. This despite the fact that the product used was an inferior one: an early generation electronic cigarette.

The Association for Nonsmokers-Minnesota is not the only anti-smoking group that is simply ignoring the clinical evidence. In fact, I can find few anti-smoking groups that actually reported the results of the electronic cigarette clinical trial. The overwhelming majority of anti-smoking groups are simply ignoring it.

For example, Americans for Nonsmokers' Rights still falsely claims that: "there is no
scientific evidence that e-cigarettes are an effective cessation tool."

The rest of the story is that anti-smoking groups are not publicizing the results of the electronic cigarette clinical trial because they don't actually care about the scientific evidence. They have taken a pre-determined position against these products based purely on ideology (they can't possibly endorse an activity that looks like smoking) and money (many of these groups have received money from pharmaceutical companies that manufacture competing products).

About Me

Dr. Siegel is a Professor in the Department of Community Health Sciences, Boston University School of Public Health. He has 32 years of experience in the field of tobacco control. He previously spent two years working at the Office on Smoking and Health at CDC, where he conducted research on secondhand smoke and cigarette advertising. He has published nearly 70 papers related to tobacco. He testified in the landmark Engle lawsuit against the tobacco companies, which resulted in an unprecedented $145 billion verdict against the industry. He teaches social and behavioral sciences, mass communication and public health, and public health advocacy in the Masters of Public Health program.